Quality and safety: lessons from
the Francis Report
Peter Molyneux
Common Cause Consulting
10 February 2014

• No NED had current or previous clinical experience
• NED discouraged to get involved in “operational matters”
• Major organizational changes not discussed by the Board
• NEDs accepted reassurance rather than assurance
• Lack of soft intelligence or testing of reassurance
• Lack of clear clinical engagement and leadership
• Lack of tracking of action plans
• No benchmarking
• Foundation status and financial targets a distraction from
other issues
Mid-Staffordshire

Survey of Board members of housing associations, 2013:
•Quality management focused on buildings and asset
management
•Quality reports focus on KPIs for arrears, planned
maintenance, repairs, staffing levels, mandatory training, etc
•Quality management systems used a combination of user-
generated feedback, announced / unannounced inspections,
and numbers accessing training and employment
•Quality assurance systems less developed
•Very few board members felt they received proper assurance
around quality and safety of care and support services that
were provided
Quality assurance in housing associations

“Whilst quality management systems might be effective there
is little assurance being given and hence not inconsiderable
reputational risk.”
Quality assurance in housing associations

• Winterbourne View and Mid-Staffs have undermined public
confidence in health and care system
• Francis Report shows failings not restricted to any single
sector, or type of provider
• Government proposals have significant implications for HA
boards, and how they discharge their responsibility as
stewards of organisational reputation
• Combined with changes to CQC regulatory model, creates
new responsibilities for Boards, and new expectations from
stakeholders
• Introduction of fundamental standards, clear guidance
combined with an enhanced role for HSE
Changing regulatory environment

• Set of fundamental standards as part of CQC registration,
with a clear baseline below which care must never fall,
combined with tougher sanctions against providers that do
not meet these standards
• All directors of providers registered with CQC will be
required to meet a new ‘fit and proper person’ test
• CQC will consider the role of the board and individual
directors in any service failure – with the power to insist on
their removal or to prosecute in the case of serious failure
Changing regulatory environment / continued

• New statutory duty of candour: providers required to make
sure staff are open with service users and their families if
they believe there have been failings in treatment or care,
and to provide an explanation for it
• An improved and strengthened inspection regime will focus
on a risk based approach using inspection teams that are
more experienced in the delivery and scrutiny of frontline
services
Changing regulatory environment / continued



Performance against quality KPI
•Compliance with regulatory requirements and standards
•Key risk areas and mitigations
•Trends and areas for improvement
•Summary of any external assessments / reports / inspection
in period
Incident management
•Narrative, trends and areas for improvements
Quality report

Workforce
•Vacancy rates, turnover, bank and agency, etc
•Staff feedback summary
•Staff engagement activity
Customer involvement
•Internally commissioned surveys – customer surveys, real-
time, any-time
•Announced and unannounced visits – discovery visits, spot
checks, customer audits, etc
•Compliments, complaints and MP enquiries
Quality report / continued

• High level document for use by the Board
• Sets out strategic risks which threaten the organisation’s
strategic objectives
• Assesses controls and gaps in these
• Records means of assurance and gaps
• Assigns responsibility, timing and monitoring for mitigating
actions on controls and assurances
Board assurance framework

1. Measuring outcomes that matter most to service users
2. Ensuring the organisation has identified the strategic risks to
the delivery of its objectives and desired outcomes, and is
aware of gaps in assurance
3. Demonstrating triangulation of different types of data and
use independent sources of assurance
4. Scrutinising quality and safety, and asking the right
questions: vital to ensuring there is a culture that challenges
the normalisation of variance from required standards
5. Boards are informed about performance against key quality
indicators, risks to delivery of quality
6. Risks to reputation given equal weight to financial risks
Six-step pathway to quality assurance